ABSTRACT
@#Introduction: The Ministry of Health (MOH) implemented the MalaysianDRG casemix system in 2010, and two national target indicators on the accuracy and completeness of clinical documentation were introduced to measure its performance. This study aims to show the trend of casemix performance in MOH hospitals and to explore the challenges in meeting these targets. Methods: The study design was sequential explanatory mixed-method design. First, a cross-sectional study described the trend of casemix performance in five MOH hospitals in Malaysia. Second, a single holistic case study of the hospital with the lowest casemix system performance was conducted to explore the perceptions of clinicians regarding the MalaysianDRG casemix and the challenges pertaining to clinical documentation. Purposive sampling was employed, and the case study data collection was carried out using in-depth-interviews, observation, and document reviews. Results: Two hospitals achieved the target in the accuracy of clinical documentation for the main condition (≥90%). For completeness in clinical documentation, four out of five MOH hospitals performed below the target (≤ 60%). Thematic analysis of the data found poor commitment of clinicians towards casemix and a multitude of obstacles in performing clinical documentations. Conclusion: After a decade of its implementation, the performance of the MalaysianDRG casemix system in MOH hospitals is still moderate due to inaccurate and incomplete clinical documentations. The study findings may be used to spread awareness and devise tailored solutions to assist clinicians in paving the way towards future excellence in MalaysianDRG casemix system.
ABSTRACT
Se presenta un estudio de caso en el contexto de la gestión de la información clínica sanitaria, en el que, a partir de la revisión de la literatura científica, se detectó que las tecnologías de la información se han ido introduciendo de manera desigual e irregular en la sanidad pública española. El estudio se planteó como objetivo analizar cómo se realiza un proyecto de digitalización de historias clínicas, el cual condujo a las siguientes preguntas de investigación: ¿Cómo se gestiona la información sanitaria? ¿Cómo se realiza un proyecto de digitalización de historias clínicas en un contexto real? ¿Qué formación tienen los profesionales que participan en el proceso y ¿cuál es el papel de los documentalistas? Se siguió una metodología de investigación cualitativa con perspectiva naturalista, además del análisis de la literatura científica, en la que se presentaron los resultados del estudio basados en la dotación de equipamiento, el servicio de consultoría, la gestión documental y de archivo, además del perfil profesional que se plantea para la ejecución de un proyecto de digitalización de historias clínicas. Se concluye que la gestión de la información no satisface las necesidades del personal sanitario; que no existe un procedimiento documentado para la digitalización de las historias clínicas y que no se requiere la participación de profesionales sanitarios ni de documentalistas, a pesar de que la literatura científica resalta la inestimable participación de estos profesionales(AU)
A health information management case study is presented in a which scientific literature review revealed that information technologies have been incorporated into Spanish public health in an uneven, irregular manner. To corroborate this fact we set ourselves the objective of analyzing the way in which a medical record digitalization project is conducted, which led to the following research questions: How is health information managed? How is a medical record digitalization project conducted in a real life context? What is the background of professionals involved in the process and what is the role of documentalists? Besides examination of the scientific literature, a naturalist qualitative analysis was performed in which the results of the study were presented, based on equipment provision, advisory service, document management and archiving, and the professional profile established for the conduct of a medical record digitalization project. It is concluded that information management does not meet the needs of the health personnel, that a documented procedure is not available for medical record digitalization, and that participation of health professionals and documentalists is not requested, despite the scientific literature highlighting the invaluable participation of these professionals(AU)
Subject(s)
Humans , Male , Female , Electronic Health Records , Health Information Management/methods , Health Services , Hospital Administration/methods , SpainABSTRACT
Introdução: Documentar as ações e informações associadas ao cuidado oferecido ao paciente é uma preocupação constante para os profissionais da saúde. Na enfermagem o planejamento das atividades relacionadas ao cuidado segue um modelo conhecido como Processo de Enfermagem, realizado em cinco etapas: avaliação, diagnóstico, resultados do paciente, prescrição e evolução. Cada etapa deve ser documentada com precisão passando a integrar os registros do prontuário clínico. Essa documentação pode ser avaliada por meio de indicadores: medidas que quantificam os aspectos mensuráveis de uma variável, usadas em programas de melhoria da qualidade. Objetivo: propor indicadores de qualidade da documentação clínica de enfermagem. Método: estudo metodológico, desenvolvido em três etapas: teórica, empírica e analítica. A etapa teórica compreendeu: geração de tópicos de conteúdo e itens de análise documental mediante revisão bibliográfica; análise de conteúdo e semântica realizada por cinco especialistas, dois enfermeiros recém- formados e oito graduandos em enfermagem que revisaram e validaram as definições conceituais e operacionais dos tópicos e as descrições dos itens quanto a sua elegância, clareza e pertinência; confecção do instrumento de avaliação da documentação clínica de enfermagem (IADOCE). Na etapa empírica foi realizada a análise da documentação de enfermagem em 204 prontuários clínicos de pacientes internados por quatro ou mais dias, em 2013, em dois hospitais do município de São Paulo (A e B). Cada prontuário foi analisado por dois enfermeiros (avaliação interpares) que verificaram de forma independente os registros de enfermagem de três datas: da internação, da data central do período de permanência e data de saída do sistema de cuidados. A confiabilidade interpares foi analisada pelo Kappa de Cohen e intervalo de confiança 95%. Na fase final foram propostos sete indicadores da documentação clínica de enfermagem. Para o cálculo dos indicadores foi considerado o percentual de conformidade dos registros documentais com os critérios de avaliação estabelecidos. Resultados: Das 316 descrições de tópicos de conteúdo e itens compilados mediante revisão da literatura, após as análises da etapa teórica, sugestões dos especialistas e pré-teste, resultaram em um instrumento com sete tópicos de conteúdo e 88 itens chamado Instrumento de Avaliação da Documentação Clínica de Enfermagem (IADOCE). A concordância interavaliadores, analisada pelos valores de Kappa situou-se entre mediana e quase perfeita: em 67,3% foi quase perfeita, em 21,2% forte; nos 11,5% restantes, entre moderada e mediana. Foi proposto um Indicador de Qualidade da Documentação Clínica global (IQDCGlobal), derivado de sete IQDC parciais, entre os quais se distribuíram 88 critérios. A conformidade da documentação avaliada com os critérios dos indicadores propostos variou de 0,5% a 100,0%; os IQDC variaram entre 62,33% e 93,48% na instituição A e 72,18% e 84,23% na instituição B. O IQDC global mostrou diferença de 2,1% entre as duas amostras avaliadas. Conclusões: o estudo permitiu propor sete indicadores da qualidade da documentação clínica de enfermagem e o método para sua utilização em prontuários hospitalares. Novos estudos permitirão adequá-los ao uso em outros contextos do cuidado.
Introduction: Documenting the actions and information associated with the care offered to the patient is a constant concern for health professionals. In nursing, the planning of activities related to care follows a model known as the Nursing Process, carried out in five stages: assessment, diagnosis, patient results, prescription and evaluation. Each step must be accurately documented and integrated into the records of the clinical record. This documentation can be evaluated using indicators: measures that quantify the measurable aspects of a variable, used in quality improvement programs. Aim: to propose quality indicators for clinical nursing documentation. Method: methodological study, developed in three stages: theoretical, empirical and analytical. The theoretical stage comprised: generation of content topics and documentary analysis items through bibliographic review; content and semantics analysis carried out by five specialists, two newly graduated nurses and eight nursing undergraduates who reviewed and validated the conceptual and operational definitions of the topics and the item descriptions regarding their elegance, clarity and relevance; making the assessment instrument for clinical nursing documentation (IADOCE). In the empirical stage, the analysis of nursing documentation was performed on 204 clinical records of patients hospitalized for four or more days, in 2013, in two hospitals in the city of São Paulo (A and B). Each medical record was analyzed by two nurses (peer review) who independently checked the nursing records for three dates: admission, the central date of the period of stay and the date of leaving the care system. Peer reliability was analyzed by Cohen\'s Kappa and 95% confidence interval. In the final phase, seven indicators of clinical nursing documentation were proposed. For the calculation of the indicators, the percentage of compliance of the documentary records with the established evaluation criteria was considered. Results: of the 316 descriptions of content topics and items compiled through literature review, after the analysis of the theoretical stage, suggestions from experts and pre-test, resulted in an instrument with seven content topics and 88 items called Documentation Assessment Instrument Nursing Clinic (IADOCE). The inter-rater agreement, analyzed by the Kappa values, was between median and almost perfect: in 67.3% it was almost perfect, in 21.2% strong; in the remaining 11.5%, between moderate and median. A global Clinical Documentation Quality Indicator (IQDCGlobal) was proposed, derived from seven partial IQDCs, among which 88 criteria were distributed. The conformity of the assessed documentation with the criteria of the proposed indicators ranged from 0.5% to 100.0%; the IQDC varied between 62.33% and 93.48% in institution A and 72.18% and 84.23% in institution B. The global IQDC showed a difference of 2.1% between the two samples evaluated. Conclusion: the study allowed us to propose seven indicators of the quality of clinical nursing documentation and the method for its use in hospital records. New studies will allow them to be adapted for use in other care contexts.